APAGE Symposium. Prof. Chyi-Long Lee & Prof. Mitsuru Shiota. PROGRAM Co-CHAIRS. Advancing Minimally Invasive Gynecology Worldwide.

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1 APAGE Symposium PROGRAM Co-CHAIRS Prof. Chyi-Long Lee & Prof. Mitsuru Shiota Prashant Mangeshikar, MD Hsuan Su, MD Sponsored by AAGL Advancing Minimally Invasive Gynecology Worldwide

2 Table of Contents Course Description... 1 Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) in Adnexal Procedures C. Lee, H.Su... 2 Demystifying the Total Laparoscopic Hysterectomy P. Mangeshikar... 9 Cultural and Linguistics Competency... 13

3 APAGE Symposium Professor Chyi-Long Lee and Professor Mitsuru Shiota, Co-Chairs Faculty: Dr. Preshant Mangeshikar, Dr. Hsuan Su Course Description Natural orifice transluminal endoscopic surgery (NOTES) uses the natural orifices of human body (ex, mouth, anus, etc.) as port of laparoscopy to achieve a scarless abdominal surgery. Though the techniques of transcolonic or transesophageal accesses have also been developed, the transvaginal access is the most frequently used and suitable for gynecologists. The first course, Transvaginal NOTES in Adnexal Procedures, provides its technical details and feasibility evaluation. Hysterectomy is one of the most commonly performed surgical procedures. Total laparoscopic hysterectomy (TLH) is characterized by performing all the procedures and disconnecting the uterus from pelvic floor with solely abdomen approach. The second course, Demystifying the Total Laparoscopic Hysterectomy, provides the technical details, points out the key principle of operative safety, and offers the tips and tricks of achieving a successful TLH. Learning Objectives At the conclusion of this course, the participant will be able to: 1) Illustrate the techniques of both procedures; 2) recognize the advantages and limitations of both procedures; and 3) select appropriate patients to perform the procedures. Course Outline 1:10 Welcome, Introductions and Course Overview M.Shiota, C. Lee 1:15 Transvaginal Natural-Orifice Transluminal Endoscopic Surgery (NOTES) in Adnexal Procedures C. Lee, H.Su 1:40 Demystifying the Total Laparoscopic Hysterectomy P. Mangeshikar 2:05 Questions & Answers All Faculty 2:10 Adjourn 1

Division of Gynecologic Endoscopy, Department of Obstetrics and

minimal invasive surgery Share the experience of Chang Gung Memorial

4 Transvaginal Natural-Orifice Transluminal Endoscopic Surgery (NOTES) in Adnexal Procedures No financial relationships to disclose Hsuan Su M.D. Division of Gynecologic Endoscopy, Department of Obstetrics and Gynecology To explain the retinal of NOTES procedure in gynecologic minimal invasive surgery Share the experience of Chang Gung Memorial hospital Surgical procedure NOTES What is NOTES Natural-Orifice Transluminal Endoscopic Surgery 2

First NOTES like procedure What is NOTES In Gynecology Endoscopic surgery through Vagina Culdocopy: Von Ott D. 1902 Culdoscopy Diagnostic & Operative procedure Decker A.

1975;82:318 320 Culdoscopy -Criticized Transvaginal hydrolaparoscopy Restricted visualization Limited operative capabilities Risk of infection Fertility evaluation Darai E,

5 First NOTES like procedure What is NOTES In Gynecology Endoscopic surgery through Vagina Culdocopy: Von Ott D Culdoscopy Diagnostic & Operative procedure Decker A. Culdoscopy; its diagnostic value in pelvic disease. JAMA. 1949;140: orz Paldi E, Timor-Tritsch I, Abramovici H, Peretz BA. Operative culdoscopy. Br J Obstet Gynaecol. 1975;82: Culdoscopy -Criticized Transvaginal hydrolaparoscopy Restricted visualization Limited operative capabilities Risk of infection Fertility evaluation Darai E, Dessolle L, Lecuru F, Soriano D. Transvaginal hydrolaparoscopy compared with laparoscopy for the evaluation of infertile women: a prospective comparative blind study. Hum Reprod. 2000;15:

Hsuan Su Limitation Poor visual distance Port unstable CGMH Kim TJ, et al. Single-port access laparoscopic adnexal surgery.

6 Vaginal approach Common skill for gynecologists 2007 culdoscopy Limitation for gynecological procedures - Too deep to identify the target - Too close to proceed the procedure Hsuan Su Hydrosalpinx, salpingectomy 2 cases 2007 culdoscopy 2010 Vaginal glove port Hsuan Su Limitation Poor visual distance Port unstable CGMH Kim TJ, et al. Single-port access laparoscopic adnexal surgery. J Minim Invasive Gynecol. 2009;16: Vaginal glove port 2010 Vaginal glove port Karl Storz 0 or 30 degree 5 mm or 10 mm telescope 4

Single incision laparoscopic surgery, SILS Vaginal endoscopic surgery, VES 2010 Vaginal

sterilization - - Hysterectomy via transvaginal natural orifice transluminal endoscopic

2012 Jun;51(2):217-21 Transvaginal natural-orifice transluminal endoscopic surgery (NOTES)

7 Single incision laparoscopic surgery, SILS Vaginal endoscopic surgery, VES 2010 Vaginal endoscopic surgery, VES May 2010 First NOTES hysterectomy Aug 2010 First NOTES tubal sterilization - - Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES): Feasibility of an innovative approach Su H. et al Taiwan J Obstet Gynecol Jun;51(2): Transvaginal natural-orifice transluminal endoscopic surgery (NOTES) in adnexal procedures Lee CL, et al J Minim Invasive Gynecol Jul-Aug;19(4): Epub 2012 Mar Vaginal endoscopic surgery, VES Vagina Hsuan Su 2010 Vaginal endoscopic surgery, VES Wound retractor 2010 Vaginal endoscopic surgery, VES Wound retractor Hsuan Su Hsuan Su 5

2010 Vaginal endoscopic surgery, VES Wound retractor

Let triangulation become possible Rigid scope and

8 2010 Vaginal endoscopic surgery, VES Wound retractor Hsuan Su The result is. Create an adequate visual distance, and made vaginal surgery a reality Bigger port diameter. Let triangulation become possible Rigid scope and instruments transvaginal endoscopic surgery First case tubal ligation before After Tube Ovary Tube Ovary 6

9 2010 transvaginal endoscopic surgery 2010 transvaginal endoscopic surgery Right endometrioma, before Right endometrioma, after Right Left Right Left 2010 transvaginal endoscopic surgery Video of NOTES cystectomy Advantage Limitation Following embryologic anatomy Can not inspect whole pelvis, endometriosis? Less pain Loss of triangulation Faster recover Instruments limitation Scarless Anatomy re-establish 7

Indication of NOTES adnexal surgery NOTES adnexal surgery Teratoma Tubal sterilization Ectopic pregnancy Benign adnexal neoplasm Endometriosis?

10 Indication of NOTES adnexal surgery NOTES adnexal surgery Teratoma Tubal sterilization Ectopic pregnancy Benign adnexal neoplasm Endometriosis? Several months later NOTES adnexal surgery NOTES adnexal surgery Conclusion Transvaginal endoscopic surgery for adnexal procedures is an alternative method with a well patient selection Surgical outcome should be evaluated The limitation of the procedure should be explored 1. Von Ott D. Die Beleuchtung der Bauchhohle (Ventroskopie) als Methode bei Vaginaler Coeliotomie. Abl Gynakol. 1902;231: Decker A. Culdoscopy; its diagnostic value in pelvic disease. JAMA. 1949;140: Paldi E, Timor Tritsch I, Abramovici H, Peretz BA. Operative culdoscopy.br J Obstet Gynaecol. 1975;82: Darai E, Dessolle L, Lecuru F, Soriano D. Transvaginal hydrolaparoscopy compared with laparoscopy for the evaluation of infertile women: a prospective comparative blind study. Hum Reprod. 2000;15: Kim TJ, et al. Single port access laparoscopic adnexal surgery. J Minim Invasive Gynecol. 2009;16: Su H. et al Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES): Feasibility of an innovative approach Taiwan J Obstet Gynecol Jun;51(2): Lee CL, et al J Transvaginal natural orifice transluminal endoscopic surgery (NOTES) in adnexal procedures Minim Invasive Gynecol Jul Aug;19(4): Epub 2012 Mar Lee CL, Huang KG, Jain S, Wang CJ, Yen CF, Soong YK. A new portal for gynecologic laparoscopy.jam Assoc Gynecol Laparosc Feb;8(1): Ahn KH, Song JY, Kim SH, Lee KW, Kim T. Transvaginal single port natural orifice transluminal endoscopic surgery for benign uterine adnexal pathologies J Minim Invasive Gynecol Sep;19(5): Epub 2012 Jul 3. 8

Demystifying the Total Laparoscopic Hysterectomy Prashant Mangeshikar Mumbai INDIA AAGL 41 st Global Congress of Minimally Invasive

Adnexal masses (not suspicious) Adhesions (from previous laparotomy) Large Size uteri The Difficult TLH Knowledge of Anatomy Knowledge of

Hysterectomy Instrumentation Trocar Cannula Short Self Retaining Valve: Silicon and suture friendly Scissors Ultrasonic Energy ESU:

Technique easily reproducible Reusable Instruments Energy Sources Suturing Skills Total Laparoscopic Hysterectomy Instrumentation EndoTIP:

11 Demystifying the Total Laparoscopic Hysterectomy Prashant Mangeshikar Mumbai INDIA AAGL 41 st Global Congress of Minimally Invasive Gynecology, Las Vegas, November 2012 Understanding the Difficult TLH Difficult Vaginal Access Low mobility of the Severe Endometriosis Adnexal masses (not suspicious) Adhesions (from previous laparotomy) Large Size uteri The Difficult TLH Knowledge of Anatomy Knowledge of Instrumentation Knowledge of Technique Knowledge of Difficulties Knowledge of possible Complications Knowledge of Limits Total Laparoscopic Hysterectomy Instrumentation Trocar Cannula Short Self Retaining Valve: Silicon and suture friendly Scissors Ultrasonic Energy ESU: Monopolar and Bipolar Grasping Forceps Mangeshikar Knot Pusher Koh Needle Holders: Right and Left versions The Difficult TLH made Easy Technique easily reproducible Reusable Instruments Energy Sources Suturing Skills Total Laparoscopic Hysterectomy Instrumentation EndoTIP: Safe Visual Abdominal Entry of Primary Portal Uterine Manipulation: Mangeshikar Uterine Mobilizar Telescope: 0 and 30 degree Laparoscope Bariatric Telescope: Extra 10 cm long 9

12 TLH for the Large The Difficult TLH made Easy Visual Abdominal Entry: EndoTIP Cannula Approach: Primary Portal Lee Huang Point High Pressure Entry: Pneumoperitoneal 20 mms. Hg. or more TLH for the Large TLH for the Large Accessory Portals: Number: 3 or 4 Koh Point: Rt. & Lt 5 mms. self retaining Hunt Reich Cannulas with Silicon valves TLH for the Large Total Laparoscopic Hysterectomy Visualisation Approach: 10 mms. Telescope Degree: 0 and 30 Longer Length: Bariatric Exposure Uterine Manipulation Access 10

13 MANGESHIKAR UTERINE MOBILIZAR Mobilize the uterus in multi directions TLH for the Large Mangeshikar Uterine Mobilizar Present the Vaginal Fornices Maintain Pneumoperitoneum Vaginal Delineating Tube Medical Grade Polypropylene Tube OD 30 ~ 40 mm Lifts Vagina Upwards Displaces Ureter, Bladder and Rectum outside surgical fie Uterine vessels well delineated against the rim The Difficult TLH made Easy Energy Sources The Difficult TLH Monopolar Energy: Pure Cut 80W Bipolar Energy: 40 W Reusable RoBi (Robust Bipolar) Forceps Harmonic Scalpel Is Robotic Hysterectomy y the Answer? Robots are for the Handicapped!!! Charles Koh 11

Remember: The MAGIC is in the MAGICIAN and NOT in the WAND Video NO

14 The Difficult TLH Faculty Disclosure No Financial Relationships to Disclose Does LSK have LIMITS? The Surgeon himself! Remember: The MAGIC is in the MAGICIAN and NOT in the WAND Video NO QUILLS AND NO BARBS USED NO ROBOT WAS USED DURING THIS SURGERY ONLY SURGICAL SKILLS AND DEXTERITY 12

15 CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as the AAGL, to assist in enhancing the cultural and linguistic competency of California s physicians (researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP). US Population Language Spoken at Home California Language Spoken at Home English Spanish Spanish Indo-Euro Asian Other English Indo-Euro Asian Other 19.7% of the US Population speaks a language other than English at home In California, this number is 42.5% California Business & Professions Code (c)(3) requires a review and explanation of the laws identified above so as to fulfill AAGL s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the program, the importance of the services, and the resources available to the recipient, including the mix of oral and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of Executive Order 13166, Improving Access to Services for Persons with Limited English Proficiency, signed by the President on August 11, was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies, including those which provide federal financial assistance, to examine the services they provide, identify any need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access. Dymally-Alatorre Bilingual Services Act (California Government Code 7290 et seq.) requires every California state agency which either provides information to, or has contact with, the public to provide bilingual interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population. If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills. A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. ~ 13

Program Schedule. 3 rd Annual Collaborative Symposium: Update in Minimally Invasive Gynecologic Surgery

Program Schedule. 3 rd Annual Collaborative Symposium: Update in Minimally Invasive Gynecologic Surgery Program Schedule 3 rd Annual Collaborative Symposium: Update in Minimally Invasive Gynecologic Surgery Thursday, February 5, 2015 6:45 a.m. Registration and Breakfast 7:25 a.m. Welcome / Announcements